Before prescribing VERQUVO, please read the accompanying Prescribing Information, including the Boxed Warning about embryo-fetal toxicity. The Medication Guide also is available.
Before prescribing VERQUVO, please read the accompanying Prescribing Information, including the Boxed Warning about embryo-fetal toxicity. The Medication Guide also is available.
To get started, select a category above or call 855-591-7980 to speak with a representative, Monday through Friday, 8 AM to 8 PM ET
CO-PAY COUPON FOR VERQUVO
Not all patients are eligible. Certain restrictions apply.
Independent Foundation Support
Your patients may also be able to get help from an independent co-pay assistance foundation
Independent co-pay assistance foundations may be able to help patients who are encountering hardships affording their prescribed medications or who do not qualify for other forms of financial support.
Each foundation determines its own eligibility criteria and application process and is independent from Merck; there is no guarantee a patient will receive any type of assistance from these organizations.
REMEMBER TO: 
Sign & Submit Electronically
REMEMBER TO: Sign & Submit Electronically
 |
Use this option to complete the enrollment form electronically with the patient |
|
Fill out and sign the healthcare provider section of the enrollment form |
|
Inform the patient that they will receive an email from The Merck Access Program to complete the enrollment form |
|
Instruct the patient to complete and sign the patient sections of the enrollment form |
|
Submit the enrollment form electronically |
REMEMBER TO:
Download & Print
REMEMBER TO: Download & Print
|
Download and print the enrollment form |
|
Instruct the patient to complete and sign the patient sections of the enrollment form (pages 1-4) |
|
Fill out and sign the healthcare provider section of the enrollment form (pages 5-6) |
|
Include a copy of the front and back of the patient’s insurance card |
|
Fax the completed form to 833-996-3275 |
REMEMBER TO:
|
Complete the patient and insurance information (page 1) |
|
Fill out and sign the healthcare provider section of the enrollment form (pages 2-3) |
|
Submit the enrollment form electronically |
|
Ensure the patient also completes the Electronic Patient Enrollment Form, found at merckaccessprogram-verquvo.com/hcc/ |
